A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain.
The client is short of breath and difficult to arouse.
During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?

Administer a narcotic reversal drug.

Apply an oxygen face mask.

Remove the morphine patches.

Monitor the client’s blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering a narcotic reversal drug is not the first action the nurse should take. While it’s true that the client’s symptoms could be due to opioid overdose, the nurse should first confirm the cause of the symptoms. In this case, the nurse finds four patches on the client’s body, which is unusual and could lead to an overdose. Therefore, the first action should be to remove the patches to prevent further absorption of the drug.

Choice B rationale

Applying an oxygen face mask might be necessary if the client is having difficulty breathing. However, this would not address the underlying problem if the client is experiencing an overdose from the morphine sulfate patches. The nurse should first remove the patches to stop further drug absorption.

Choice C rationale

The nurse finds four patches on the client’s body. This is unusual and could lead to an overdose. Therefore, the nurse’s first action should be to remove the patches to prevent further absorption of the drug. After removing the patches, the nurse can assess the client’s condition and provide further interventions as needed.

Choice D rationale

Monitoring the client’s blood pressure is an important nursing intervention, but it should not be the first action in this situation. The nurse has already found a potential cause for the client’s symptoms (i.e., the four morphine sulfate patches). Therefore, the first action should be to address this problem by removing the patches.

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Correct Answer is A

Explanation

Choice A rationale

Labetalol is a non-selective beta-blocker used to treat hypertension. The goal of labetalol administration is to reduce the blood pressure to 140/90 mmHg, and the diastolic BP must not fall below 90 mmHg. However, in this scenario, the client’s heart rate is 48 beats/minute, which is lower than the normal range (60-100 beats/minute). Administering labetalol, which can further decrease heart rate, could lead to bradycardia, a condition that can cause fainting, fatigue, or chest discomfort. Therefore, the nurse should withhold the scheduled dose and notify the healthcare provider.

Choice B rationale

While it is important to monitor the client’s BP regularly when administering labetalol, given the client’s low heart rate, administering the dose could potentially exacerbate the client’s bradycardia. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice C rationale

Assessing for orthostatic hypotension before administering the dose is an important consideration when administering medications that can lower blood pressure. However, in this case, the client’s low heart rate is a more immediate concern. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice D rationale

Applying a telemetry monitor could help in monitoring the client’s heart rate and rhythm. However, given the client’s current heart rate, the priority should be to withhold the medication and inform the healthcare provider.

A. Obtain an extra pillow for the client to use at night. B. Give a PRN prescription for benztropine. C. Provide the client a heating pad to place on the neck. D. Obtain a prescription for physical therapy services.

Correct Answer is B

Explanation

Choice A rationale

Obtaining an extra pillow for the client to use at night may provide some comfort, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck could be a sign of a condition known as akathisia, a common side effect of antipsychotic medications. Akathisia is characterized by a feeling of restlessness and a compulsion to move, and it can often be misinterpreted as anxiety or agitation.

Choice B rationale

Administering a PRN prescription for benztropine is the most appropriate intervention. Benztropine is an anticholinergic medication that is often used to manage the extrapyramidal side effects of antipsychotic medications, such as akathisia. By reducing these side effects, the client’s comfort and adherence to the antipsychotic medication regimen can be improved.

Choice C rationale

Providing the client with a heating pad to place on the neck may offer temporary relief, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck is likely a symptom of akathisia, a side effect of antipsychotic medications. Therefore, interventions should be aimed at managing this side effect rather than just addressing the symptom.

Choice D rationale

Obtaining a prescription for physical therapy services is not the most appropriate immediate response. While physical therapy can be beneficial for many conditions, it is not typically used as the first-line treatment for akathisia, a common side effect of antipsychotic medications.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

Correct Answer is A

Explanation

A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?

Correct Answer is B

Explanation

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